Provider Demographics
NPI:1588341960
Name:SEPULVEDA, ERNESTO JOSUE
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:JOSUE
Last Name:SEPULVEDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 AVE AMERICO MIRANDA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-2842
Mailing Address - Country:US
Mailing Address - Phone:787-274-8326
Mailing Address - Fax:
Practice Address - Street 1:1008 AVE AMERICO MIRANDA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-2842
Practice Address - Country:US
Practice Address - Phone:787-274-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11046183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician